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Types of breast cancer

There are several different types of breast cancer, which can develop in different parts of the breast.

Breast cancer is often divided into:

non-invasive breast cancer (carcinoma in situ) – found in the ducts of the breast (ductal carcinoma in situ, DCIS) and hasn't developed the ability to spread outside the breast. It's usually found during a mammogram and rarely shows as a breast lump.

invasive breast cancer – usually develops in the cells that line the breast ducts (invasive ductal breast cancer) and is the most common type of breast cancer. It can spread outside the breast, although this doesn't necessarily mean it has spread.

It's possible for breast cancer to spread to other parts of the body, usually through the bloodstream or the axillary lymph nodes. These are small lymphatic glands that filter bacteria and cells from the mammary gland.

If this happens, it's known as secondary, or metastatic, breast cancer.

Breast cancer screening

Mammographic screening, where X-ray images of the breast are taken, is the most commonly available method of detecting an early breast lesion.

However, you should be aware that a mammogram might fail to detect some breast cancers.

It might also increase your chances of having extra tests and interventions, including surgery, even if you're not affected by breast cancer.

Women with a higher-than-average risk of developing breast cancer may be offered screening and genetic testing for the condition.

As the risk of breast cancer increases with age, all women who are 50 to 70 years old are invited for breast cancer screening every three years.

Women over the age of 70 are also entitled to screening and can arrange an appointment through their GP or local screening unit.

The NHS is in the process of extending the programme as a trial, offering screening to some women aged 47 to 73.

It's been suggested that regular exercise can reduce your risk of breast cancer by as much as a third. Regular exercise and a healthy lifestyle can also improve the outlook for people affected by breast cancer.

If you've been through the menopause, it's particularly important that you're not overweight or obese.

This is because being overweight or obese causes more oestrogen to be produced, which can increase the risk of breast cancer.

Breast awareness

It's important to be breast aware so you can pick up any changes as soon as possible.

Get to know what is normal for you – for instance, your breasts may look or feel different at different times of your life. This will make it much easier to spot potential problems.

Causes

The causes of breast cancer aren't fully understood, making it difficult to say why one woman may develop breast cancer and another may not.

However, there are risk factors known to affect your likelihood of developing breast cancer. Some of these you can't do anything about, but there are some you can change.

Age

The risk of developing breast cancer increases with age. The condition is most common among women over 50 who have been through the menopause. About 8 out of 10 cases of breast cancer occur in women over 50.

All women who are 50 to 70 years of age should be screened for breast cancer every three years as part of the NHS Breast Screening Programme.

Women over the age of 70 are still eligible to be screened and can arrange this through their GP or local screening unit.

Family history

If you have close relatives who have had breast cancer or ovarian cancer, you may have a higher risk of developing breast cancer.

However, because breast cancer is the most common cancer in women, it's possible for it to occur in more than one family member by chance.

Most cases of breast cancer don't run in families, but particular genes known as BRCA1 and BRCA2 can increase your risk of developing both breast and ovarian cancer. It's possible for these genes to be passed on from a parent to their child.

Other newly detected genes, such as TP53 and CHEK 2, are also associated with an increased risk of breast cancer.

If you have, for example, two or more close relatives from the same side of your family – such as your mother, sister or daughter – who have had breast cancer under the age of 50, you may be eligible for surveillance for breast cancer, or genetic screening to look for the genes that make developing breast cancer more likely.

If you're worried about your family history of breast cancer, discuss it with your GP.

Radiation

If you had radiotherapy to your chest area for Hodgkin lymphoma when you were a child, you should have already received a letter from the Department of Health inviting you for a consultation with a specialist to discuss your increased risk of developing breast cancer.

See your GP if you weren't contacted or if you didn't attend a consultation. You're usually entitled to having your breast checked with an MRI scan.

If you currently need radiotherapy for Hodgkin lymphoma, your specialist should discuss the risk of breast cancer before your treatment begins.

Hormone replacement therapy (HRT)

Both combined HRT and oestrogen-only HRT can increase your risk of developing breast cancer, although the risk is slightly higher if you take combined HRT.

It's estimated there will be an extra 19 cases of breast cancer for every 1,000 women taking combined HRT for 10 years. The risk continues to increase slightly the longer you take HRT, but returns to normal once you stop taking it.

The prolonged use of HRT is not usually recommended, especially if you find it possible to cope with symptoms of the menopause.

Contraceptive pill

Research has shown that women who use the contraceptive pill have a slightly increased risk of developing breast cancer.

However, the risk starts to decrease once you stop taking the pill, and your risk of breast cancer is back to normal 10 years after stopping.

Diagnosis

Tests at the breast cancer clinic

If you have suspected breast cancer, either because of your symptoms or because your mammogram has shown an abnormality, you'll be referred to a specialist breast cancer clinic for further tests.

Mammogram and breast ultrasound

If you have symptoms and have been referred to a specialist breast unit by your GP, you'll probably be invited to have a mammogram, which is an X-ray of your breasts. You may also need an ultrasound scan.

If your cancer was detected through the NHS Breast Screening Programme, you may need another mammogram or ultrasound scan.

Your doctor may suggest that you only have a breast ultrasound scan if you're under the age of 35. This is because younger women have denser breasts, which means a mammogram isn't as effective as ultrasound in detecting cancer.

Ultrasound uses high-frequency sound waves to produce an image of the inside of your breasts, showing any lumps or abnormalities.

Your breast specialist may also suggest a breast ultrasound if they need to know whether a lump in your breast is solid or contains liquid.

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Stage and grade of breast cancer

Stage of breast cancer

When your breast cancer is diagnosed, the doctors will give it a stage. The stage describes the size of the cancer and how far it has spread, and helps to predict the outlook.

Ductal carcinoma in situ (DCIS) is sometimes described as stage 0. Other stages of breast cancer describe invasive breast cancer:

stage is the tumour is "in situ" and there's no evidence of invasion (pre-invasive)

stage 1 the tumour measures less than 2cm and the lymph nodes in the armpit aren't affected; there are no signs that the cancer has spread elsewhere in the body

stage 2 the tumour measures 2-5cm, the lymph nodes in the armpit are affected, or both; there are no signs that the cancer has spread elsewhere in the body

stage 3 the tumour measures 2-5cm and may be attached to structures in the breast, such as skin or surrounding tissues, and the lymph nodes in the armpit are affected; there are no signs that the cancer has spread elsewhere in the body

stage 4 the tumour is of any size and the cancer has spread to other parts of the body (metastasis)

This is a simplified guide. Each stage is divided into further categories: A, B and C. If you're not sure what stage you have, ask your doctor.

TNM staging system

The TNM staging system may also be used to describe breast cancer, as it can provide accurate information about the diagnosis:

T the size of the tumour

N whether the cancer has spread to the lymph nodes

M whether the cancer has spread to other parts of the body

Grade of breast cancer

The grade describes the appearance of the cancer cells.

low grade (G1) the cells, although abnormal, appear to be growing slowly

medium grade (G2) the cells look more abnormal than low-grade cells

high grade (G3) the cells look even more abnormal and are more likely to grow quickly

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Treatment

Treatment overview

Surgery is usually the first type of treatment for breast cancer. The type of surgery you undergo will depend on the type of breast cancer you have.

Surgery is usually followed by chemotherapy or radiotherapy or, in some cases, hormone or biological treatments. Again, the treatment you'll have will depend on the type of breast cancer.

Your doctor will discuss the most suitable treatment plan with you. Chemotherapy or hormone therapy will sometimes be the first treatment.

Secondary breast cancer

Most breast cancers are discovered in the condition's early stages. However, a small proportion of women discover that they have breast cancer after it's spread to other parts of the body (metastasis).

If this is the case, the type of treatment you have may be different. Secondary cancer, also called "advanced" or "metastatic" cancer, isn't curable.

Treatment aims to achieve remission, where the cancer shrinks or disappears, and you feel normal and able to enjoy life to the full.

Surgery

In many cases, a mastectomy can be followed by reconstructive surgery to try to recreate a bulge to replace the breast that was removed.

Studies have shown that breast-conserving surgery followed by radiotherapy is as successful as total mastectomy at treating early-stage breast cancer.

Breast-conserving surgery

Breast-conserving surgery ranges from a lumpectomy or wide local excision, where just the tumour and a little surrounding breast tissue is removed, to a partial mastectomy or quadrantectomy, where up to a quarter of the breast is removed.

If you have breast-conserving surgery, the amount of breast tissue you have removed will depend on:

the type of cancer you have

the size of the tumour and where it is in your breast

the amount of surrounding tissue that needs to be removed

the size of your breasts

Your surgeon will always remove an area of healthy breast tissue around the cancer, which will be tested for traces of cancer.

If there's no cancer present in the healthy tissue, there's less chance that the cancer will return.

If cancer cells are found in the surrounding tissue, more tissue may need to be removed from your breast.

After having breast-conserving surgery, you'll usually be offered radiotherapy to destroy any remaining cancer cells.

Mastectomy

A mastectomy is the removal of all the breast tissue, including the nipple.

If there are no obvious signs that the cancer has spread to your lymph nodes, you may have a mastectomy, where your breast is removed, along with a sentinel lymph node biopsy.

If the cancer has spread to your lymph nodes, you'll probably need more extensive removal (clearance) of lymph nodes from the axilla under your arm.

Reconstruction

Breast reconstruction is surgery to make a new breast shape that looks like your other breast as much as possible.

Reconstruction can be carried out at the same time as a mastectomy (immediate reconstruction), or it can be carried out later (delayed reconstruction).

It can be done either by inserting a breast implant or by using tissue from another part of your body to create a new breast.

Lymph node surgery

To find out if the cancer has spread, a procedure called a sentinel lymph node biopsy may be carried out.

The sentinel lymph nodes are the first lymph nodes that the cancer cells reach if they spread. They're part of the lymph nodes under the arm (axillary lymph nodes).

The position of the sentinel lymph nodes varies, so they're identified using a combination of a radioisotope and a blue dye.

The sentinel lymph nodes are examined in the laboratory to see if there are any cancer cells present. This provides a good indicator of whether the cancer has spread.

If there are cancer cells in the sentinel nodes, you may need further surgery to remove more lymph nodes from under the arm.

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Predict: decide on the ideal course of treatment following breast cancer surgery

Radiotherapy

Radiotherapy uses controlled doses of radiation to kill cancer cells. It's usually given after surgery and chemotherapy to kill any remaining cancer cells.

If you need radiotherapy, your treatment will begin about a month after your surgery or chemotherapy to give your body a chance to recover.

You'll probably have radiotherapy sessions three to five days a week, for three to six weeks. Each session will only last a few minutes.

The type of radiotherapy you have will depend on your cancer and the type of surgery you have. Some women may not need to have radiotherapy at all.

The types available are:

breast radiotherapy after breast-conserving surgery, radiation is applied to the whole of the remaining breast tissue

chest wall radiotherapy after a mastectomy, radiotherapy is applied to the chest wall

breast boost some women may be offered a boost of high-dose radiotherapy in the area where the cancer was removed; however, the boost may affect the appearance of the breast, particularly if you have large breasts, and can sometimes have other side effects, including hardening of the breast tissue (fibrosis)

radiotherapy to the lymph nodes where radiotherapy is aimed at the armpit (axilla) and the surrounding area to kill any cancer that may be present in the lymph nodes

The side effects of radiotherapy include:

irritation and darkening of the skin on your breast, which may lead to sore, red, weepy skin

Chemotherapy

It's usually used after surgery to destroy any cancer cells that haven't been removed. This is called adjuvant chemotherapy.

In some cases, you may have chemotherapy before surgery, which is often used to shrink a large tumour. This is called neo-adjuvant chemotherapy.

Several different medications are used for chemotherapy, and three are often given at once.

The choice of medication and the combination will depend on the type of breast cancer you have and how much it's spread.

Chemotherapy is usually given as an outpatient treatment, which means you won't have to stay in hospital overnight. The medications are usually given through a drip straight into the blood through a vein.

In some cases, you may be given tablets that you can take at home. You may have chemotherapy sessions once every two to three weeks, over a period of four to eight months, to give your body a rest in between treatments.

The main side effects of chemotherapy are caused by their influence on normal, healthy cells, such as immune cells.

However, this doesn't always happen and you may enter an early menopause. This is more likely in women over 40, as they're closer to menopausal age.

Your doctor will discuss the impact any treatment will have on your fertility with you.

Chemotherapy for secondary breast cancer

If your breast cancer has spread beyond the breast and lymph nodes to other parts of your body, chemotherapy won't cure the cancer, but it may shrink the tumour, relieve your symptoms and help lengthen your life.

Hormone treatment

Some breast cancers are stimulated to grow by the hormones oestrogen or progesterone, which are found naturally in your body.

These types of cancer are known as hormone receptor-positive cancers. Hormone therapy works by lowering the levels of hormones in your body or by stopping their effects.

The type of hormone therapy you'll have will depend on the stage and grade of your cancer, which hormone it's sensitive to, your age, whether you've experienced the menopause, and what other type of treatment you're having.

You'll probably have hormone therapy after surgery and chemotherapy, but it's sometimes given before surgery to shrink a tumour, making it easier to remove.

Hormone therapy may be used as the only treatment for breast cancer if your general health prevents you having surgery, chemotherapy or radiotherapy.

In most cases, you'll need to take hormone therapy for up to five years after having surgery. If your breast cancer isn't sensitive to hormones, hormone therapy will have no effect.

Tamoxifen

Tamoxifen stops oestrogen from binding to oestrogen-receptor-positive cancer cells. It's taken every day as a tablet or liquid.

Biological therapy (targeted therapy)

Some breast cancers are stimulated to grow by a protein called human epidermal growth factor receptor 2 (HER2). These cancers are called HER2-positive.

Biological therapy works by stopping the effects of HER2 and helping your immune system to fight off cancer cells.

If you have high levels of the HER2 protein and are able to have biological therapy, you'll probably be prescribed a medicine called trastuzumab.

Trastuzumab, also known by the brand name Herceptin, is usually used after chemotherapy.

Trastuzumab

Trastuzumab is a type of biological therapy known as a monoclonal antibody.

Antibodies occur naturally in your body and are made by your immune system to destroy harmful cells, such as viruses and bacteria.

The trastuzumab antibody targets and destroys cancer cells that are HER2-positive.

Trastuzumab is usually given intravenously, through a drip. It's also sometimes available as an injection under the skin (a subcutaneous injection).

You'll have the treatment in hospital. Each treatment session takes up to one hour, and the number of sessions you need will depend on whether you have early or more advanced breast cancer.

On average, you'll need a session once every three weeks for early breast cancer, and weekly sessions if your cancer is more advanced.

Trastuzumab can cause side effects, including heart problems. This means that it's not suitable if you have a heart problem, such as angina, uncontrolled high blood pressure (hypertension), or heart valve disease.

If you need to take trastuzumab, you'll have regular tests on your heart to make sure it's not causing any problems.

Other side effects of trastuzumab may include:

an initial allergic reaction to the medication, which can cause nausea, wheezing, chills and fever

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Clinical trials

A great deal of progress has been made in breast cancer treatment, and more women now live longer and have fewer side effects from treatment.

These advances were discovered in clinical trials, where new treatments and treatment combinations are compared with standard ones.

All cancer trials in the UK are carefully overseen to ensure they're worthwhile and safely conducted. In fact, participants in clinical trials can do better overall than those in routine care.

If you're asked to take part in a trial, you'll be given an information sheet and, if you want to take part, you'll be asked to sign a consent form. You can refuse or withdraw from a clinical trial without it affecting your care.

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Psychological help

Dealing with cancer can be a huge challenge for both patients and their families. It can cause emotional and practical difficulties.

Many women have to cope with the removal of part or all of a breast, which can be very upsetting.

It often helps to talk about your feelings or other difficulties with a trained counsellor or therapist. You can ask for this kind of help at any stage of your illness.

There are various ways to find help and support. Your hospital doctor, specialist nurse or GP can refer you to a counsellor.

If you're feeling depressed, talk to your GP. A course of antidepressant drugs may help, or your GP can arrange for you to see a counsellor or psychotherapist.

It can help to talk to someone who's been through the same thing as you. Many organisations have helplines and online forums. They can also put you in touch with other people who've had cancer treatment.

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Living with

Recovery and follow-up

Recovery

Most women with breast cancer have an operation as part of their treatment. Getting back to normal after surgery can take some time. It's important to take things slowly and give yourself time to recover.

During this time, avoid lifting things – for example, children or heavy shopping bags – and avoid heavy housework. You may also be advised not to drive.

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Reconstruction

If you didn't have immediate breast reconstruction carried out when you had a mastectomy, you can have reconstruction later. This is called a delayed reconstruction.

There are two main methods of breast reconstruction:

reconstruction using your own tissue

reconstruction using an implant

The type that's most suitable for you will depend on many factors, including the treatment you've had, any ongoing treatment, and the size of your breasts. Talk to your healthcare team about which reconstruction is suitable for you.

It's also been suggested that regular exercise can reduce your risk of developing breast cancer by as much as a third.

If you've been through the menopause, it's particularly important that you're not overweight or obese. This is because these conditions cause more oestrogen to be produced by your body, which can increase the risk of breast cancer.

Breastfeeding

Studies have shown women who breastfeed are statistically less likely to develop breast cancer than those who don't.

The reasons aren't fully understood, but it could be because women don't ovulate as regularly while they're breastfeeding and oestrogen levels remain stable.

Treatments to reduce your risk

If you have an increased risk of developing breast cancer, treatment is available to reduce your risk.

Your level of risk is determined by factors such as your age, your family's medical history and the results of genetic tests.

You'll usually be referred to a specialist genetics service if it's thought you have an increased risk of breast cancer. Healthcare professionals working at these services should discuss treatment options with you.

The two main treatments are surgery to remove the breasts (mastectomy) or medication. These are described in more detail below.

Mastectomy

A mastectomy is surgery to remove the breasts. It can be used to treat breast cancer and reduce the chances of developing the condition in the small number of women from high-risk families.

By removing as much breast tissue as possible, a mastectomy can reduce your risk of breast cancer by up to 90%.

However, like all operations, there's a risk of complications, and having your breasts removed can have a significant effect on your body image and sexual relationships.

If you want to, you can usually choose to have a breast reconstruction either during the mastectomy operation or at a later date.

During breast reconstruction surgery, your original breast shape is recreated using either breast implants or tissue from elsewhere in your body.

An alternative is to use breast prostheses. These are artificial breasts that can be worn inside your bra.

An alternative to mastectomy is a nipple-sparing mastectomy, where the whole mammary gland is removed, but the skin envelope is preserved. This is not widely available at the moment, but it's being used more often and can achieve excellent results.

Medication

Two medications, called tamoxifen and raloxifene, are available on the NHS for women who have an increased risk of developing breast cancer.

Either tamoxifen or raloxifene can be used in women who've been through the menopause, but only tamoxifen should be used in women who haven't.

These medications may not be suitable if you've had blood clots or womb cancer in the past, or if you have an increased risk of developing these problems in the future.

Women who've already had a mastectomy to remove both breasts won't be offered these medications as their risk of developing breast cancer is very small.

A course of treatment with tamoxifen or raloxifene will usually involve taking a tablet every day for five years.

Raloxifene can cause side effects including flu-like symptoms, hot flushes and leg cramps. Side effects of tamoxifen can include hot flushes and sweats, changes to your periods, and nausea and vomiting.

Your chances of giving birth to a child with birth defects increase while you're taking tamoxifen, so you'll be advised to stop taking it at least two months before trying for a baby.

The medication can also increase your risk of blood clots, so you should stop taking it six weeks before having any planned surgery.

Tamoxifen and raloxifene aren't currently licensed for the purpose of reducing the risk of breast cancer in women with an increased risk of developing the condition.

However, they can still be used if you understand the benefits and risks, and your doctor believes the treatment will be helpful.

"I asked my GP if there was any screening programme they could put me into when I was 25, because my mother died from breast cancer when she was 32. They referred me to the Royal Victoria Infirmary, and I used to come once a year just for a check-up.

"A few years later I was in the bath and I noticed a lump under my left armpit. I didn't quite know what to make of it. I was quite worried at first.

"I went to see my GP the next day and he suspected that it might just be a cyst, as I was only 28 at the time. But because of my family history, he referred me to a specialist.

"At the hospital, I had an ultrasound, a mammogram and a needle biopsy. When I returned a week later for the results, they confirmed that I had breast cancer and that I would need to come in for lumpectomy surgery 10 days later.

"I had chemotherapy for six months after my first diagnosis, followed by five weeks of radiotherapy. It was really hard. All my hair fell out and it made me feel so ill.

"My husband Graham was great, and tried to support me as best he could throughout it. My sister-in-law was never off the phone and my best friend Claire was lovely.

"My sister handled it in a very different way. She had watched my mum become very poorly, and then her older sister was diagnosed. She found it hard to deal with and she just couldn't handle coming to see me. She later admitted being terrified that it might be her next.

"The second time I was diagnosed, I had a bigger operation – a double mastectomy. The decision to have a mastectomy was quite easy to make. For me, it was the only decision, having had cancer twice.

"The reality after the event was very different. With the reconstructive surgery as well, I knew it would be a long recovery, but I don't think anything prepared me for just how long. I cried every single day because I was so uncomfortable.

"I was referred to a psychologist, who told me I wasn't going mad. Anyone who'd been through what I had would be expected to have a few tearful days. Things settled down, then it was just a case of trying to get back to normal.

"Looking back at everything, I wouldn't have changed my decision at all. It was definitely for the best.

"I now have check-ups every six months with my oncologist, breast surgeons, and at the family clinic. I see my plastic surgeon, my geneticist, and have an ultrasound once a year, plus a blood test every four months as part of the ovarian screening programme.

"The Macmillan breast care nurses ring me up every once in a while to keep me up-to-date and check that I'm all right. I'm very well looked after.

"Now I just want to stay cancer free. I've done as much as I possibly can to prevent it from coming back or getting a new cancer. I didn't quite make it after my first diagnosis, but I'd like to get through the next five years without the cancer returning.

"My advice to other women would be to speak to your breast care nurse or go on the Cancer Research UK or Breast Cancer Care websites. There are so many recognised sources of information.

"The internet is full of horror stories, so make sure you get as much information as you can from reputable sources."